VOL: 96, ISSUE: 42, PAGE NO: 39
Scott Forrest, BSc, RMN, RGN, is an infection control nurse in public health, Lothian Health, Edinburgh
The number of patients diagnosed with methicillin-resistant Staphylococcus aureus has shot up in recent years. The reasons are complex and involve a number of different factors, which include the use of antibiotics and the management of patients in hospitals and in the community.
The working party report by the Hospital Infection Society (1998) is an important document. It recognises that for MRSA to be managed effectively there must be risk assessment at local level. This can only be successful if the decision-making process is carried out by those fully aware of the unique circumstances of each hospital and individual clinical areas. Patients with MRSA require a treatment programme that reflects their individual needs and not one which could be perceived as meeting the wider needs of the organisation. While patient care must always be a team effort, no group is better equipped to make a meaningful contribution to this issue than the nursing profession.
The working party identified high, medium, low and minimal risk categories of patient care. High-risk areas were those such as intensive care units. Medium-risk areas were identified as surgical wards. Low risk were medical units and minimal risk applied to care of the elderly, psychiatry and psychogeriatric facilities.
Adopting a risk assessment approach to patients with MRSA can assist in the planning of their individual care. The development of such an approach exemplifies how nurses at local level, working with the infection control team, can improve patient care.
A risk assessment is defined as a systematic identification of hazards or risks to health (Wilson, 1995). It can be used to identify patients who are particularly likely to develop infection and so allow preventive measures to be introduced. It is clear that not all patients with MRSA pose the same degree of risk. Fig 1 provides a framework for managing patients with MRSA more effectively and with greater sensitivity.
MRSA risk assessment matrix
- Score 2: Topical eradication treatment should be attempted at least once. If unsuccessful, no further treatment should be considered unless discussed with a member of the infection control team.
- Score 3-5: Patients who are colonised should be considered for five days’ topical eradication treatment. Patients who have either an MRSA-infected wound or a MRSA systemic infection may also require antibiotics. Patients must be isolated where the risk to other patients has been clinically assessed as unacceptable. Patients in the high-risk wards must always be nursed in source isolation, as should patients in the medium-risk wards, unless alternative arrangements have been agreed with the infection control team.
- Score 6: It is acceptable to postpone topical treatment of MRSA if the patient’s condition makes it inappropriate at that time. Patients who cannot be nursed in source isolation may be prescribed topical eradication treatment to reduce carriage/risk of cross-infection.
How patients benefit
A patient in a care of the elderly ward who has MRSA would score either two or a maximum of three on the matrix. The ward team may choose to screen the patient every few months to confirm whether they remained MRSA-positive. Systemic/ wound infection would be treated, but the patient would not need to be nursed in isolation.
Patients who are in wards/areas designated in the low/medium categories of risk could possibly benefit the most from the risk assessment matrix. Patients with MRSA in the low/medium-risk wards can score a minimum of three up to a maximum of five points. Patients with MRSA in certain wards may not pose a significant risk to fellow patients. By using the matrix the nurses and other members of the team can use their skills and knowledge to assess the risk factors which are unique to their specific ward/environment. Some patients may need to be isolated while others could be nursed in an open ward.
Patients in high-risk wards can score a minimum of five up to a maximum of six on the matrix. Patients with MRSA in wards/areas designated as high risk, such as intensive care, coronary care and high-dependency units, oncology, haematology and surgical, should always be cared for in isolation. The potential risk to other patients is unacceptable.
Patients in the minimal-risk wards do not require routine or contact screening. In all other areas, patients in the immediate vicinity of an affected patient should have block screens, with swabs taken from the nose, throat, axillae and groins processed as one specimen and, where indicated, CSU (catheter specimen of urine), sputum and invasive devices as individual samples (Fig 2).
Pre-treatment screening of newly diagnosed MRSA patients consists of a full individual screen, where nose, throat, axillae and groin are handled as separate, individual specimens. Pre-treatment screening should also include samples from wounds and invasive devices plus CSU, and/or sputum where appropriate. Post-treatment screening should be block screens plus individual samples of wounds and invasive devices, including CSU and/or sputum where appropriate.
The risk assessment matrix in figure 1 is not complicated or carved in stone. Each hospital environment is unique and much discussion will be necessary before an acceptable format is developed for each organisation. With some thought, the matrix (Fig 1), screening information (Fig 2) and topical treatment regime (Fig 3) will fit on one A4 page. This can be laminated and distributed to all clinical areas.
It is possible for nurses to make a positive contribution to the control of MRSA. The development of a risk assessment matrix coupled with a review of screening and treatment regimes can improve patient care. A risk assessment approach can lead to fewer patients being nursed in isolation with reduced and simplified screening regimes. Treatment programmes can be more patient-focused.
The natural progression from the risk assessment matrix would be to examine the development of a clinical pathway system.
- The full version of this article can be found on our website at nursingtimes.net.